The Current and Future Financial Burden of Hospital Admissions for Heart Failure in Canada: a Cost Analysis
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CMAJ OPEN Research The current and future financial burden of hospital admissions for heart failure in Canada: a cost analysis Dat T. Tran MPH, Arto Ohinmaa PhD, Nguyen X. Thanh MD PhD, Jonathan G. Howlett MD, Justin A. Ezekowitz MBBCh MSc, Finlay A. McAlister PhD, Padma Kaul PhD Abstract Background: Heart failure is a costly health condition and a major public health concern. We sought to examine the costs of hospital admissions for heart failure between fiscal years 2004 and 2013 in Canada and to model the future costs to 2030. Methods: Canadian Institutes for Health Information Discharge Abstract Database was used to identify admissions to hospital with heart failure as the primary diagnosis between fiscal years 2004 and 2013. Multiple linear regression models were used to calculate the trend in prevalence and extrapolate these to 2030. Canadian Institutes for Health Information patient cost estimates were used to identify costs of hospital admissions for heart failure. Generalized linear models were used to estimate average annual costs per heart failure patient. We conducted a sensitivity analysis including all admissions for heart failure in any diagnostic field. Results: In 2013, 45 600 (95% confidence interval [CI]: 43 800–47 200) patients were admitted with heart failure as the primary diag- nosis, accounting for $482 (95% CI $464–$500) million. By 2030, we estimate 54 000 (95% CI 49 000–60 000) patients and costs of $722 (95% CI $650–$801) million, with older adults (age ≥ 80 yr) accounting for 52% of costs. Including admissions for which heart failure was a secondary diagnosis increases the total cost to $2.8 (95% CI $2.6–$3.0) billion in 2030. Interpretation: As in other developed countries, hospital costs related to heart failure in Canada are on the rise. Older adults are the main consumers of such hospital services. Strategies to improve outpatient care to reduce rates of admission for heart failure are needed. eart failure is a costly health condition and a major Methods public health problem. It is estimated that 2%–3% H of the population in developed countries has heart Annual volume of patients from 2004 to 2013 (all of failure, and the prevalence increases to 8% among patients Canada except Quebec) aged more than 75 years.1 Heart failure is the single most The Canadian Institute for Health Information Hospital common reason for hospital admission.2,3 In the United Discharge Abstract Database from 2004 to 2013 for all States, it was projected that there would be 8.5 million people Canadian provinces and territories except Quebec was used (3% of the US population) with heart failure in 2030, which to identify hospital admissions with a primary diagnosis of would cost the US health system $53 billion.4 heart failure (International Statistical Classification of Diseases It has been hypothesized that a combination of and Related Health Problems, 10th revision, code I50). improved survival in heart failure patients5–7 and population Canadian population estimates for the same period from aging8 is expected to increase the burden of this condition Statistics Canada9 (minus Quebec) were used as denominators in Canada. However, little is known as to the current and to calculate annual prevalence rates per 100 000 population by future financial burden of heart failure on the Canadian sex and age (< 60 yr, 60–69 yr, 70–79 yr and ≥ 80 yr). Patients health care system. with multiple admissions for heart failure during the same The objectives of our study were to examine hospital year were counted once. admission costs for heart failure between fiscal years 2004 and 2013 in Canada and, based on these costs, model the future prevalence and admission costs to 2030. Although Competing interests: None declared. long-term heart failure prevalence and costs in Canada may This article has been peer reviewed. change as a result of new therapies or changes in manage- ment strategies, forecasts based on current trends can serve Correspondence to: Padma Kaul, [email protected] as useful benchmarks to examine the effects of future inno- CMAJ Open 2016. DOI:10.9778/cmajo.20150130 vations on health care costs. © 2016 Joule Inc. or its licensors CMAJ OPEN, 4(3) E365 CMAJ OPEN Research Estimating national volume of heart failure patients used Canadian population estimates (medium population from 2004 to 2013 (including Quebec) growth — M5) from 2014 to 20308,17 to calculate the expected We did not have data on admissions for heart failure for the number of heart failure patients for each year. The annual province of Quebec. To calculate national estimates for the total admission costs for 2014–2030 were then derived by burden of heart failure, we assumed the prevalence rates of multiplying the expected number of admitted patients with hospital admission for heart failure in Quebec to be the aver- the annual admission cost per patient. age across all other provinces and territories and used multiple linear regression (natural logarithm of prevalence rate as the Sensitivity analyses dependent variable) with fiscal year, sex, age group and the We conducted 3 sensitivity analyses. First, we examined the interaction between sex and age as independent variables in the uncertainty around our annual cost estimates by varying the model. Joinpoint regression was used5,10–12 to detect significant estimated average annual admission cost per patient within its changes in annual prevalence rates between 2004 and 2013. 95% confidence interval (CI). Second, we added low and high We recorded significant turning points at anα level of 0.05 to population growth scenarios8,17 into projections of prevalence use as a knot in the multiple linear regression model. Model and costs from 2014 to 2030. Finally, we recalculated preva- assumptions (homoscedasticity, normality of residuals, and the lence and cost estimates based on admissions for which heart linearity of relationships between the outcome and fiscal year failure was coded as either a primary or secondary diagnosis. as a continuous predictor) were checked and explored for Our primary analysis is based on admission for which heart unusual and influential observations by examining residuals failure was coded as the primary diagnosis. However, heart and leverage values. The number of patients was derived by failure has been shown to be associated with other conditions, multiplying the estimated prevalence rate from the multiple such as acute coronary syndromes and renal disease. It is linear regression model with the Canadian population (includ- therefore possible that when heart frailure is present as a sec- ing Quebec) for each age and sex group for each year. ondary diagnosis, it could contribute to hospital costs. Annual hospital costs per heart failure patient from Results 2004 to 2013 The cost of each admission to hospital was obtained from the Characteristics of the study population (all provinces Canadian Institute for Health Information, where the patient except Quebec) cost estimates were made using an algorithm that took case mix Between 2004 and 2013, there were 421 121 hospital admis- groups, resource intensity weight, cost per weighted case and sions with a primary diagnosis of heart failure in Canada, length of stay into consideration. This calculation provides aver- excluding Quebec (Table 1). The mean expected length of stay age costs incurred through the direct care of hospital inpatients for an admission increased from 7.5 days in 2004 to 8.3 days in (e.g., inpatient nursing, diagnostic and therapeutic costs).13,14 For 2013. However, the median acute length of stay remained sta- case mix groups that did not have cost available in the Canadian ble at 6 days. The number of admissions and patients both Institute for Health Information data, we used the Ontario Case reached the lowest point in 2007 and then increased. Female Costing Initiative15 instead. All costs were converted to 2014 patients outnumbered male patients in the first 3 years. Patient dollars using the Bank of Canada inflation calculator.16 Annual mean age increased over time, as did the proportion of patients inpatient costs for a heart failure patient were derived by sum- over the age of 80 years. Diabetes, chronic obstructive pulmo- ming costs of all hospital admissions of that patient in a year. nary and renal diseases were the most common comorbidities We fitted a generalized linear model with gamma distribution among heart failure patients. The largest increase in comor- and log link to estimate average annual admission costs per bidity rate was for diabetes, which increased from 29.3% in patient for the entire study period (2004–2013). The variables 2004 to 45.7% in 2013. Proportion of patients with more than included in the model were fiscal year, patient sex and age 1 admission with heart failure as the primary diagnosis per year group. Other patient factors were not included because they increased from 17.9% in 2004 to 18.8% in 2013. were already incorporated into the Canadian Institute for Health Information patient cost estimate algorithm. National volume of heart failure patients from 2004 The annual total hospital admission costs associated with to 2013 (including Quebec) heart failure in Canada from 2004 to 2013 were derived by The results of the multiple linear regression model to estimate multiplying the estimated number of patients admitted with the prevalence rate of heart failure hospital admissions over the annual hospital cost per patient. time for each age and sex group are shown in Appendix 1 (available at www.cmajopen.ca/content/4/3/E365/suppl /DC1). Projection of heart failure prevalence and costs from These rates declined over time in all groups (Figure 1). The 2014 to 2030 prevalence rates were more than 100 times higher in the oldest We assumed that the trend seen during 2004 to 2013 would compared with the youngest groups in both sexes.